Intraluminal Latex Tubing for Microsurgical Training

Since the advent of microsurgery, plastic surgeons have often relied on free flaps for more complex reconstructions. Moreover, microsurgical procedures are part of the armamentarium of several specialties other than plastic surgery such as hand surgery, otolaryngology, and maxillofacial surgery, among others. Thus, training of microsurgical skills has become an integral part of many specialist programs.

Microsurgery is neither easy to perform nor easy to learn. Because of its complexity, it cannot be acquired by observation and sporadic training, and it certainly cannot be taught directly in patients. Trainees are required considerable and continuous laboratory practice to achieve good results, namely high patency rates. Such practice involves use of various models, all trying to simulate the real clinical setting. Latex sheets and tubes, silicone tubes, foliage leaf, and different animal models are current examples.[1] Undoubtedly, the ones that more closely resemble the clinical scenario are animal models; however, these are not always readily available because of increasing regulations regarding ethical use of laboratory animals and cost. To overcome this issue, dead chicken wings and legs are a valid inexpensive alternative. Nevertheless, one of the drawbacks of this model is that due to dehydration, vessels are collapsed and often have a “slug-like” consistency that is somewhat different from a living patent vessel and thus more difficult to manipulate and suture. By freezing both artery and vein, a better consistency can be obtained,[2] however, the vessels must be sacrificed and anastomosed isolated from the whole piece. Again, clinical reality is lost, since microsurgery often is performed in the vicinity of soft tissue similar to that found in the chicken, where muscles and bone surround the vessels. Thus, to practice microsurgery in an inexpensive and readily available model such as the chicken, with vessels of consistency similar to that of living models (especially the artery since the vein is also often collapsed in living models), we have developed the use of an intraluminal latex tube. This is a simple method in which a latex tube obtained from the rolled rim/sleeve of nonsterile latex gloves is inserted into the lumen through a small incision made in the vessel wall (Fig. [1A–D]).[3] Then the vessel is cut and sutured at any point, preferably a few centimeters away from the previous wall incision to avoid tearing during manipulation and practice. Finally, the latex tube can be easily removed to test patency of the vascular anastomosis by injecting saline through the above-mentioned vessel incision. We have found this technique to be simple, inexpensive, and easy to perform. We are aware that avoiding posterior wall catching is essential in microsurgical training and that our model keeps the needle not to reach the back wall; however, this idea pretends to be an intermediate step between artificial (i.e., silicone tubes) and living models. Furthermore, the latex tube can be hollowed before insertion and thus a vessel of good consistency and with a true lumen is obtained. We have seen that trainees that first practice microsurgical anastomosis with the latex tube inside are more confident afterward in living models or even in the chicken without the intraluminal tube, in which vessels are often collapsed and difficult to manipulate, and have no problems with posterior wall catching. In our opinion, this method is a valid stage to consider in the microsurgical training route, achieving fair similarity to clinical setting superior to that of latex tubes or cryopreserved vessels alone, without the financial and ethical considerations of living models.

Figure 1 (A) A 2-mm vessel dissected; (B) latex tube inserted through a small incision on the vessel wall; (C) the vessel and intraluminal tube are cut and prepared for microsurgical anastomosis; (D) microsurgical anastomosis is completed and the latex tube pieces removed.

REFERENCES

• 1 Chan W Y, Matteucci P, Southern S J. Validation of microsurgical models in microsurgery training and competence: a review.  Microsurgery. 2007;  27 (5) 494-499
• 2 Hontanilla B, Casale C. Evaluation of freezing in arterial microsurgical anastomosis.  J Reconstr Microsurg. 2010;  26 (5) 325-333
• 3 Dustagheer S, Brown A P. Synthetic latex conduits as an aid for microsurgical training.  Plast Reconstr Surg. 2008;  122 (1) 321